Provider Demographics
NPI:1073056073
Name:TRELLIS, MARCIA (SPECIAL ED TEACHER)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:TRELLIS
Suffix:
Gender:F
Credentials:SPECIAL ED TEACHER
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:
Other - Last Name:ROSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:445 ATKINS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-4411
Mailing Address - Country:US
Mailing Address - Phone:718-207-9839
Mailing Address - Fax:
Practice Address - Street 1:445 ATKINS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208-4411
Practice Address - Country:US
Practice Address - Phone:718-207-9839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY077252011101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1811310295Medicaid